GRAND JURY REPORT

Final Draft Response to the 2007-08
Grand Jury Final Report Part 3
EL DORADO COUNTY
BOARD OF SUPERVISORS
September 16, 2008
TABLE OF CONTENTS
Use of El Dorado County Vehicles.......................................................... 3
Emergency Permits in the Development Services Department .............. 10
Audit of Human Services and Mental Health Medi-Cal Revenues ...... 15
APPENDIX A .................................................................................. 22
APPENDIX B .................................................................................. 43
El Dorado County Procurement Department ....................................... 45
Victim Restitution .................................................................................. 50
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
EL DORADO COUNTY GRAND JURY 2007-2008
Use of El Dorado County Vehicles
Case No. 07-030
REASON FOR REPORT
The El Dorado County Grand Jury received complaints regarding the use of County-owned
vehicles designated as “take-home” vehicles. There was also media attention to the subject
matter. Specifically, these complaints questioned why some County employees were
assigned permanent and overnight retention of County-owned vehicles when they seemingly
did not qualify under the requirements specified in the Board of Supervisors (BOS) Policy
#D-4 for Vehicle Use, Standards, Procurement and Disposal, adopted 12/22/87 and revised
6/20/06. After initial review of the complaints the Grand Jury determined there was
sufficient cause to investigate the use of County-owned vehicles.
BACKGROUND
The County owns 542 vehicles, although only 475 are specifically managed by Fleet
Management. These vehicles range from passenger cars to heavy-duty vehicles for use by
our Department of Transportation (DOT). Currently 83 vehicles in this fleet are assigned to
individual employees of the County and are driven to and from their respective residences.
The Board Of Supervisors Policy #D-4 sets forth rules regarding the use and operation of
vehicles while on official County business; the assignment, use, operation, procurement and
disposal of County-owned vehicles, and the methods used by the County to meet business
transportation needs of County employees.
The County’s Fleet Management Unit in the Department of General Services operates a
vehicle pool and coordinates department requests for leased, rented, or purchased vehicles to
make them available to County departments. Where appropriate, County vehicles are
assigned to specific County departments and managed by Fleet Management.
County department heads are responsible for ensuring compliance with all provisions of the
BOS Policy and maintaining and monitoring vehicle usage logs.
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METHODOLOGY
The Grand Jury gathered data from many sources. Personnel were interviewed from the
Chief Administrative Office (CAO), Auditor-Controller’s Office and General Services.
Documents Reviewed:
 Board of Supervisors Policy #D-4 For Vehicle Use, Standards, Procurement
and Disposal adopted 12/22/87 and revised 6/20/06
 Fleet Rates Spreadsheet Draft (08/09)
 General Services – Fleet Management Draft Vehicle Cost Estimates
Fiscal Year 08/09 Budget
 General Services – Fleet Management Vehicle Rate Reduced Calculations
Fiscal Year 07/08
 Take Home Vehicles 2007 Spreadsheet
FINDINGS
In accordance with the California Penal Code §933 and §933.05, each finding will be
responded to by the government entity to which it is addressed. The responses are to be
submitted to the Presiding Judge of the Superior Court. The 2007-2008 El Dorado County
Grand Jury has arrived at the following findings:
1. BOS Policy #D-4 is not being followed. Paragraph B.2 titled “Vehicle Use”
requires the CAO’s Office to review permanent assignment and overnight
retention of County-owned vehicles on an annual basis and to continue or rescind
authorization. Interviews with the CAO’s office revealed that this has not been
done for several years.
Response to Finding 1: The respondent partially disagrees with the finding. Policy D-
4 was revised in 2006 so it is inaccurate to suggest that the policy has not been followed
for “several years.” At the time of their interview with the Grand Jury, Chief
Administrative Office staff indicated that a full review of assigned vehicles has not been
done this year, but would be completed following the conclusion of the annual budget
process. Staff also indicated that the Board of Supervisors considered permanent
assignment and overnight retention of vehicles within the Department of Transportation
on March 11, 2008.
2. Paragraph B.2.a of the policy specifies that an employee who is responsible for
responding to emergency situations related to public health or safety and
protection of property on a 24-hour basis may be assigned a vehicle for on-call
duty. Those on those days the employee is assigned the on-call duty. However,
paragraph B.2.b is subject to interpretation and allows any County employee that can
demonstrate to the Board of Supervisors that it is in the best interest of the County for
that employee to be assigned permanent and overnight retention of a
County-owned vehicle.
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Response to Finding 2: The respondent agrees with the finding.
3. The purchase of County vehicle fuel is a budget item within various County
departments, and is not a component of the Fleet Management process. This is
a significant County expense…estimated to be over 1.6 million dollars next year
and represents nearly 40% of total fleet costs.
Response to Finding 3: The respondent agrees with the finding.
4. Fuel purchases for County vehicles are not centrally managed or controlled. The
County’s primary fuel vendor possesses very sophisticated reporting capabilities
and would be able to provide excellent tools in an effort to better manage
fuel purchases.
Response to Finding 4: The respondent agrees with the finding.
5. The 50 vehicles identified as “Department 99” or department owned are not
managed by Fleet Management, so the efficiency of operating those vehicles (which
represent nearly 10% of the County total) is difficult to determine.
Response to Finding 5: The respondent agrees with the finding.
6. County fleet costs for 2008-2009 are estimated to be 4.2 million dollars, with
projected total miles at over 5.4 million. These costs represent a cost to the County of
77.2 cents for every mile driven. As a point of reference, the rate the County
reimburses employees to drive their own vehicles on County business is 50.5 cents
per mile, or 26.7 cents per mile less than the County spends on its own vehicles. We
do recognize that the County per mile cost is an average of ALL vehicles, including
some heavy duty vehicles.
Response to Finding 6: The respondent partially disagrees with the finding. Section
5(b) of the county travel policy (D-1) says, “Travel by private auto in the performance of
“official County business” shall be reimbursed at the Federal rate as determined by the
Internal Revenue Service.” The IRS recently announced a new mileage reimbursement
rate for the period of 7/1/08 through 12/31/08 of 58.5 cents per mile.
7. In reviewing the take-home vehicle list many of the assignments are not for “health
and safety” or on-call status use. Take-home vehicles are driven 21% more miles per
year, per vehicle when compared to the balance of the Fleet managed vehicles. One
reason is that take-home vehicles include “commute” miles.
Response to Finding 7: The respondent agrees with the finding.
8. Potential cost savings to the County exist in two areas:
a. The conversion of miles driven in County-owned vehicles to private
vehicle reimbursement would save 26.7 cents per mile. If a 10%
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reduction were achieved, the County would save an estimated
$145,278 annually.
Response to Finding 8a: The respondent partially disagrees with the finding. As
indicated by the Grand Jury in Finding 6, the average cost per mile driven in a county
vehicle is potentially inflated by the inclusion of heavy duty vehicles which are more
expensive to purchase, operate and maintain. In addition, the Internal Revenue Service
recently announced a new mileage reimbursement rate for the period of 7/1/08 through
12/31/08 of 58.5 cents per mile. These factors combined suggest that the Grand Jury
overestimated the savings per mile to the county from increased reliance on employees’
personal vehicles. The Board of Supervisors also notes that it is infeasible to substitute
personal use vehicles for heavy duty vehicles contained in the county fleet.
More problematic however is the fact that over the past approximately 10 years, the top
selling vehicles in the County of El Dorado have been Sport Utility Vehicles and Trucks.
Nationwide the Ford F-Series truck was the top selling vehicle for over 20 years. Those
vehicles purchased over the last 10 years are currently the most commonly owned
vehicles by El Dorado residents. As shown below the ownership cost per mile of these
vehicles is well above the 58.5 cents per mile reimbursement rate. Given this negative
reimbursement rate it is unlikely to see a 10% reduction in miles driven because there is
little incentive for employees to use their own vehicles for county business.
COMMON CURRENTLY OWNED VEHICLES IN EL DORADO COUNTY
Ownership Mileage Over 5
Ownership Costs Over 5 Years at 12k Miles Per
Vehicle Model Year & Type Years Year** Ownership Cost Per Mile
2007 Chevy Tahoe $ 50,664.00 60000 $ 0.84
2007 Ford F-250 $ 58,130.00 60000 $ 0.97
2007 Ford Explorer $ 44,106.00 60000 $ 0.74
** 12,000 miles per year based on www.epa.gov
However, over the past year or so the trend has changed. The top selling vehicles in El
Dorado County are currently the Toyota Camry, the Toyota Corolla, and the Honda
Civic. The ownership cost per mile of these vehicles is far less then those historically
sold in El Dorado County, making reimbursement for some uses more acceptable in up
coming years.
COMMON CURRENT TOP SELLING VEHICLES IN EL DORADO COUNTY
Ownership Mileage Over 5
Ownership Costs Over 5 Years at 12k Miles Per
Vehicle Model Year & Type Years Year** Ownership Cost Per Mile
2007 Toyota Camry $ 30,796.00 60000 $ 0.51
2007 Toyota Corolla $ 24,743.00 60000 $ 0.41
2007 Honda Civic $ 24,952.00 60000 $ 0.42
** 12,000 miles per year based on www.epa.gov
b. A 10% reduction of total County vehicle miles driven would yield a 77.2
cent per mile savings, estimated to be $419,862 annually.
Response to Finding 8b: The respondent partially disagrees with the finding. It is
obvious that reduced driving saves money. Given the factors outlined in the response to
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finding 8a however, it is likely that the Grand Jury has overestimated the actual savings
per mile and failed to recognize the difficulty of providing a cost-effective incentive for
employees to use personal vehicles for county business. In addition, reduction in vehicle
miles incurred on county business potentially results in service reductions to the public.
The Grand Jury has not specified where these services reductions should occur or
provided a compelling rationale for why service reductions should occur.
9. Our investigation indicated that Fleet Management is performing their function well.
Response to Finding 9: The respondent agrees with the finding.
RECOMMENDATIONS
1. The CAO to complete the required annual review of permanent assignment and
overnight retention for County-owned vehicles for each County department by the
end of this calendar year. Those assignments that cannot be justified should
be rescinded.
Response to Recommendation 1: The recommendation has not yet been implemented
but will be implemented in the future. The Chief Administrative Office will complete the
required annual review by December 31, 2008.
2. Paragraph B.2 in the County vehicle policy should provide a clear definition of what
constitutes “in the best interest of the County” for assigning take-home vehicles when
the vehicle is not used for the public health and safety of citizens or does not meet the
on-call qualification.
Response to Recommendation 2: The recommendation will not be implemented
because it is not warranted. The Board of Supervisors vehicle policy is intended to
generally guide the use and assignment of vehicles but should not be interpreted to limit
the Board of Supervisors overall discretion and authority in determining the best interest
of the county.
3. The purchase of fuel for County vehicles should be consolidated under Fleet
Management so that all vehicle cost accounting and oversight is managed under a
single program.
Response to Recommendation 3: The recommendation has not yet been implemented
but will be implemented in the future. Oversight of fuel card system process should be
consolidated and standardized across all County departments. Fleet Management will
work to ensure and mandate all departments use the two card (individual driver /
individual vehicle) system. With department head discussion, a reasonable way to
control “off hour” use of take home vehicle gas cards may be the “DATE & TIME”
component of the Hunt and Sons System. A timeframe for full implementation of this
recommendation is difficult to establish, but the county expects this to be a priority when
a new Facilities and Fleet Management Directors is hired.
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4. The management of “Department 99” vehicles should be consolidated under the Fleet
Management process to insure that effective oversight and efficiency is achieved.
Response to Recommendation 4: The recommendation has not yet been implemented
but will be implemented in the future. Currently Fleet Management is only tracking
department owned vehicle smog checks. By providing oversight of individual department
owned vehicle services, safety inspections, and other required maintenance needs, the
county will ensure vehicles are safe, reliable, and remain cost effective. With the
expected addition of a third vehicle lift, Fleet will be able to accommodate those
“Department 99” vehicles currently not on a routine maintenance schedule. A
timeframe for full implementation of this recommendation is difficult to establish, but the
county expects this to be a priority when a new Facilities and Fleet Management
Directors is hired.
RESPONSES
Response(s) to this report is required in accordance with California Penal Code §933.05.
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PROJECTED 2008-2009 COUNTY VEHICLE MILES AND RELATED COSTS
TOTAL FLEET MILES: 5,437,318
COST / MILE
ALL COSTS LESS FUEL: $2,560,397 47.1 ¢

FUEL COST (407,806 gals.): $1,638,224 30.1 ¢
TOTAL COUNTY COST: $4,198,621 77.2 ¢
COUNTY PRIVATE VEHICLE REIMBURSEMENT RATE: 50.5 ¢
SPREAD BETWEEN COUNTY PER MILE COST AND REIMBURSEMENT RATE: 26.7 ¢
POTENTIAL ANNUAL SAVINGS:
> EACH 10% REDUCTION IN OVERALL MILES DRIVEN = $ 419,862
> EACH 10% CONVERSION FROM COUNTY TO PRIVATE VEHICLE = $ 145,278
% of
Vehicle Categories Count % of Fleet ManagedVehicles Miles Miles Miles/Vehicle
"Take-Home" Vehicles: 83 17.5% 1,112,350 20.5% 13,402
All Other Fleet-Managed Vehicles: 392 82.5% 4,324,968 79.5% 11,033
Total Fleet Managed Vehicles: 475 100% 5,437,318 100% 11,447
"Department 99" Vehicles: 50
Inactive Vehicles: 17
Total County Owned Vehicles: 542
NOTE: costs and miles for the 50 "Department 99" vehicles are not included, as they are not managed by Fleet Mgmnt.
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EL DORADO COUNTY GRAND JURY 2007-2008
Emergency Permits in the Development Services Department
Case No. GJ 07- 027
REASON FOR REPORT
The Grand Jury became aware of lengthy delays in the permit process for the
reconstruction of damaged buildings.
BACKGROUND
Fires, floods, earthquakes and other unexpected damage to buildings can cause great hardship to
occupants and owners. Often a business must cease or curtail operations and homeowners must
find temporary lodging until building repair or reconstruction is completed. Expediting
reconstruction is in the interest of building owners and occupants, as well as the community.
However, unlike most construction contractors, building occupants and owners struck by fire or
other emergencies are usually not familiar with the rigorous County construction permit and
inspection regulations.
The El Dorado County Board of Supervisors commissioned a study of private development review
processes conducted by the County, principally within the Development Services Department.
Results were presented in a document and power point presentation, “Permits Evaluation and
Recommended Tasks Report,” March 25, 2008. This report was aimed at changes that would
facilitate private commercial development in the County. While it made several recommendations
regarding the Development Services Department, it omitted any discussion of the Department’s
response to emergency repair and reconstruction of damaged buildings.
METHODOLOGY
The Grand Jury investigated the County Development Services Department’s process for emergency
permits. The Grand Jury interviewed several individuals and reviewed many documents.
People Interviewed:
 El Dorado County Assistant Chief Administrative Officer (interim)
 El Dorado County building contractors and business owners
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 El Dorado County Development Services Department personnel
 Fire Protection District personnel
Documents Reviewed:
 “Angora Fire Reconstruction Expedited Process,” El Dorado County Development
Services Department
 Building Permit Application (form), El Dorado County Development Services
Department
 Contractor’s Project Notes for the re-building of a damaged business
 “Fire Damage Rapid Response Permit Process,” with charts, El Dorado County
Development Services Department
 “Permits Evaluation & Recommended Tasks Report,” March 25, 2008, Assistant Chief
Administrative Officer, El Dorado County (interim)
 “Scheduling of Permits for Reconstruction of a Fire Damaged Building,” El Dorado
County Development Services Department
FINDINGS
In accordance with the California Penal Code §933 and §933.05, each finding will be responded
to by the government entity to which it is addressed. The responses are to be submitted to the
Presiding Judge of the Superior Court. The 2007-2008 El Dorado County Grand Jury has
arrived at the following findings:
1. The need for a rapid response to expedite repair and reconstruction of damaged buildings is
recognized in a Development Services Department’s document, “Fire Damage Rapid
Response Permit Process.” Grand Jury interviews provided anecdotal evidence that this
process takes much longer than necessary.
Response to Finding 1: The respondent disagrees partially with the finding. The Board of
Supervisors cannot adequately respond to anecdotal evidence presented by the Grand Jury.
Other anecdotal evidence suggests that the majority of people who have come through the
building permit process after the Angora Fire have generally been happy with the county’s
performance which suggests a timely process. In fact, approximately one-month before the
publication of the Grand Jury’s report, the county had received 165 single-family dwelling
building permit applications. 118 of those permits had been issued and one permit had been
finaled. This evidence demonstrates that the Development Services Department is appropriately
keeping up with the workload created by the Angora Fire.
2. The building construction inspection steps received little criticism. Most of the problems
were deemed to occur in the permit process. Owners of damaged buildings often don’t have
the knowledge and experience that developers have in navigating through the complicated
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process. They usually require guidance on how to proceed, both at the beginning and along
the way to the completion of the permit process. Several persons within the Development
Services Department, including outside officials such as fire marshals, are usually involved
in a series of sequential steps. There is no evidence of an overall coordinator to actually
obtain rapid response. Other than a red cover sheet (“red tag”) placed on the document
package, there was no evidence of a systemic rapid response process. The Development
Services Department has been characterized as insufficiently energetic in expediting permits
under emergency response conditions.
Response to Finding 2: The respondent disagrees partially with the finding. The Board of
Supervisors has extensively discussed the overall building permit process, as well as the specific
issues and procedures related to processing Angora Fire building permits.
It is true that many property owners choose to go through the permit process without
professional assistance. The county has no control over the expertise or prior experience of
applicants. The county attempts to educate applicants and guide them along the proper path.
However, this can add to the time it takes to process permits which subsequently causes
frustration for the applicant.
Under direction of the Development Services Director, the Chief Building Official is the master
coordinator for processing of building permits. As mentioned in the response to Finding 1, as of
the middle of May, 2008, less than 10 months after the Angora Fire, the county had issued 118
building permits out of the 165 applications it had received. Again, this evidence demonstrates
that the Development Services Department is appropriately keeping up with the workload
created by the Angora Fire.
3. Reconstruction of damaged buildings to meet current codes required by State law leads to
confusion between owners and the Development Services Department regarding the
necessary reconstruction plans and re-submittals. This leads to delays.
Response to Finding 3: The respondent agrees with the finding. As mentioned in the response
to Finding 2, many property owners choose to go through the permit process without
professional assistance. The county has no control over the expertise or prior experience of
applicants.
4. The Grand Jury found some evidence that contractors feared reprisal if they made complaints
about the permit process.
Response to Finding 4: The respondent agrees with the finding. These fears and concerns
have also been reported to the Acting Development Services Director. As a result, the Acting
Development Services Director maintains and open door policy so applicants may report
concerns and preventative or corrective measures can be taken if necessary.
RECOMMENDATIONS
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1. The County Board of Supervisors should direct the three Development Services Branch
Managers (Placerville, El Dorado Hills and South Lake Tahoe) to be master coordinators of
rapid response to all building emergencies that occur in their areas. In this capacity, their
duties should include expediting all activities related to repair and reconstruction by:
 Close supervision of all involved Department employees
 Aggressive coordination with fire marshals and other government officials outside
the Department
 Actively advising the owners and occupants of damaged buildings throughout
permitting and inspection, from beginning to completion of building repair and
reconstruction
Response to Recommendation 1: The recommendation has been implemented. This is already
a component of the permit process. As mentioned in the response to Finding 2, the Chief
Building Official is the master coordinator under the direction of the Development Services
Director. For clarification we note that the El Dorado Hills office has been closed.
2. A dated events log should be kept on each emergency response by the Branch Managers.
These logs, with relevant comments, should be reported monthly to the Director of the
Development Services Department.
Response to Recommendation 2: The recommendation has been implemented. The building
permit record itself serves as a dated events log.
3. Rapid response to emergency repair and reconstruction should be a consideration in
evaluating job performance of Branch Managers within the Development Services
Department.
Response to Recommendation 3: The recommendation has been implemented. Appropriate
evaluation requires a review of all job duties and actions. The Chief Building Official evaluates
all activities and actions of each Branch Manager during evaluation, which includes the
expeditious review of all building permit applications.
4. The (new) Director of the Development Services Department should establish an “open
door” policy in order to hear complaints from building owners and contractors on a strictly
confidential basis and make it clear to the construction community that this policy has been
adopted.
Response to Recommendation 4: The recommendation has been implemented. As mentioned
in the response to Finding 4, the Acting Director has already established this policy and, since
January, has been meeting with people expressing a wide range of concerns. This activity is
something that the Board will look to continue when a new permanent Director is selected.
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RESPONSE
Responses to this report are required in accordance with the California Penal Code §933.05
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EL DORADO COUNTY GRAND JURY 2007-2008
Audit of
Human Services and Mental Health Medi-Cal Revenues
Case No. GJ 07-006
BACKGROUND
During the past five years, the Grand Jury has received several requests for action relating to the
poor internal administrative controls in the County Departments of Human Services (DHS) and
Mental Health. The Grand Jury seated in 2005-2006 had an outside audit performed by
qualified, respected, and seasoned consultants with expertise in the Mental Health and Medi-Cal
Programs. The audit determined that both departments lacked necessary internal controls.
Specifically in the administrative areas of time-keeping, completing reports, clients receiving
incorrect information, and the programs administrated were not in compliance with State and/or
Federal laws. The major areas of concern were the financial billing, time keeping, accurate
report documentation, and recouping funds from the State of California.
A follow-up study was performed by the 2006-2007 Grand Jury and although both departments
had made improvements, still more needed to be done. (See Grand Jury reports from 2005-2006
and 2006-2007.)
In 2007, the Sacramento Bee reported the Attorney General and the Director of DHS provided an
estimate that the State’s Medi-Cal Program was losing up to one billion dollars annually due to
fraudulent activities. The Grand Jury received a less then satisfactory response into its inquiry
to both the County Departments of Mental Health and Human Services about the status of its
billing and financial reimbursement of clients’ services.
METHODOLOGY
The 2006-2007 Grand Jury voted to allocate funds to perform an audit of the financial billing
practices of both County departments in the Medi-Cal programs. The audit was initiated in
2006-2007, but was not complete by the end of the jury’s term requiring the audit to be
terminated. After a thorough analysis, the 2007-2008 Grand Jury voted to resume the audit with
Harvey Rose Associates, LLC, adjusting the audit scope to include questionable programs in
DHS and Mental Health Departments.
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FINDINGS
1. El Dorado County faces a severe budget crisis and the findings in the Audit Report provide
evidence that the County could be at risk of losing up to $541,420. If the State requested
the money be refunded, it would have to come from the County’s general fund. The
potential losses are due to administrative errors and omissions, poor policy
communications and procedures, and questionable management in the Human Services
Public Guardian Program. Conversely, the Human Services Linkages Program was found
to be well managed.
Response to Finding 1: The respondent disagrees with the finding. The Board of
Supervisors does not concur with the conclusion that the county is at risk of losing up to
$541,420 because the faulty sampling methodology used in this audit produced inaccurate
findings from which no valid extrapolations can be concluded.
In general, in order to ensure that the characteristics of a sample are representative of an
entire population, certain statistical standards must be met. The sample sizes in this audit do
not meet reasonably acceptable thresholds and their random selection is highly doubtful.
With respect to Mental Health Department, the audit indicates that 52 clients among both the
Adult Outpatient and Children’s Outpatient programs were selected initially for analysis.
Among these 52 client files, only 37 were actually reviewed. According to the California
External Quality Review Organization’s (CAEQRO) February 2008 review of the County
mental health plan, there were 1,313 beneficiaries of mental health outpatient services in
calendar year 2006. Assuming a client population of this size for 2007, in order to draw a
statistically valid inference about the entire population of clients, with a 95% confidence level
and a 5% confidence interval, 297 client files would have had to be reviewed.
This sampling error is perhaps further compounded by the way in which the sample was
selected. There are four sampling methods commonly used in clinical audits, the first three of
which are forms of probability sampling:
1. Simple Random Sampling. Each subject has an equal chance of being selected.
2. Quasi Random Sampling (or Systematic Sampling).
3. Stratified Sampling. Ensures the proportion of different groupings present in
the population is reflected in the sample.
4. Consecutive Sampling (or Convenience Sampling).
This audit reviewed billing and documentation files for selected Western Slope clients who
were provided services between the months of August and October 2007, but only for a period
of one month prior to the time actual bills were submitted to the State. For the South Lake
Tahoe Adult sample, the audit sample was limited to three billings per client between the
months of March and October 2007. This inconsistent sampling methodology suggests that the
sample was not identified randomly, as stated in the audit report. A non-random sample
further erodes the reliability of the sample, and the ability to extrapolate characteristics of the
sample to the population.
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Similar sampling errors are evident with respect to the Department of Human Services portion
of the audit. For example, the TCM Program funding component within the Linkages Program
served a total client population of 60 cases that met the Auditor’s criteria. The audit reviewed
10 cases. In order to draw a statistically valid inference about the population with a 95%
confidence level and a 5% confidence interval, 52 cases would have to be sampled. Similarly
the TCM Program funding component within Public Guardian served a total client population
of 153 cases that met the Auditor’s criteria. At a 95% confidence level with a 5% confidence
interval, 110 cases would have to be included in the sample in order to draw a valid inference.
The audit reviewed 12 cases.
Given the extremely small sample sizes, there is insufficient evidence that the rate of
disallowance suggested by the sample is representative of the Medi-Cal client file population.
The Board of Supervisors is further concerned about the auditor’s ability to draw conclusions
based on the data requested and reviewed. In particular, many of the alleged disallowances in
the Mental Health component of the audit were attributed to “incomplete client
plan/assessment notes.” It is not clear that the auditor is professionally trained in medical
documentation standards and clinical psychiatry to judge the quality of clinical progress
documents.
The audit findings relative to Targeted Case Management in the Department of Human
Services are based upon:
1) An apparent lack of understanding of the TCM Program and its requirements.
2) An apparent lack of understanding of the distinction between Medi-Cal beneficiaries and
Medi-Cal beneficiaries eligible for or receiving TCM services.
3) An apparent lack of understanding of the Public Guardian and Linkages Programs and
target populations.
4) Inaccurate underlying data due to reviewing redacted documentation.
A more detailed discussion of the audit inaccuracies affecting the audit results is available in
Appendix A.
In addition, although the audit reviewed many aspects of Medi-Cal billing practices in two
different departments, Finding 1 implies that the entire amount of “at risk” funds are due to
management of the Public Guardian Program only. Although the Board of Supervisors
believes the amounts suggested in the audit are in error, the audit itself suggests a potential
Medi-Cal disallowance for the Department of Human Services’ Public Guardian Program of
$144,828.
Finally, to the best of our knowledge, the County has no history of having these types of claims
disallowed at the rates suggested by the audit. The audit does not provide any specific state or
federal criteria indicating that disallowances would occur for the issues discussed. Even if the
documentation reviewed was out of compliance with program requirements, the documentation
deficiencies would more likely be the subject of a corrective action plan than of disallowed
costs.
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2. The Grand Jury acknowledges the difficulty in administering and implementing mental
health and human service programs. County staff is concerned and takes pride in caring
for our citizens; however, there is room for improvement.
Response to Finding 2: The respondent agrees with the finding. County staff is proud of
these programs and is always looking for opportunities to improve services.
3. The Grand Jury and the Auditor encountered multiple impediments in obtaining the
necessary legally authorized and court-ordered records from DHS. Even with repeated
County Counsel intervention, the Auditor, with the court-order, did not receive requested
client case record information, including requested assessments in effect during the review
period, pertinent to the performance of a comprehensive compliance audit. Only during the
June 9, 2008 exit conference, did DHS acquiesce to allow the Auditor and grand jurors a
chance to physically inspect the records, just six days before the audit was to be submitted
to the Grand Jury. The Auditor gave DHS every possible opportunity to comply. After the
exit conference, DHS did provide the Auditor with additional information requested. A
subsequent letter from the Assistant Director of DHS to the Grand Jury dated
June 13, 2008, extended a late invitation encouraging jurors to review the electronic
records. The invitation was received in the Grand Jury after the audit review period and
the closure of the investigation.
The impediments the Auditor experienced in acquiring information was in direct
contrast with the Department of Mental Health. The Grand Jury commends the Department
of Mental Health for their positive attitude and desire to improve customer service and
providing information requested by the Auditor while still maintaining client
confidentiality.
Response to Finding 3: The respondent disagrees partially with the finding. Client privacy
is of the utmost importance, and it is difficult to connect case management and reporting
information for individual clients without compromising protected information.
The Department of Human Services welcomed the court order issued for this audit, which was
actually a recommendation by the State of California to provide an outside auditor with access
to case files that may contain clients’ personal information. The Board of Supervisors
understands that the auditor may have been frustrated by the redactions in the documentation
provided as directed by the court order. However, during the audit process the auditor
advised the Department of Human Services staff that he had sufficient information to proceed.
Staff also notes that the auditor followed up with only limited questions about the information
provided. The Department of Human Services expected an onsite audit of the case files and
offered the auditor access to the case files with limited redactions. However, the auditor
declined the onsite file review. Since the documents requested for review would be leaving the
Department of Human Services office, staff exercised an abundance of caution in redacting
client information.
4. The results of the investigation and information from previous Grand Juries indicate that
closer oversight of the leadership in the DHS by the Board of Supervisors
is required.
18
Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
Response to Finding 4: The respondent disagrees with the finding. As stated in the response
to Finding 1, the Board of Supervisors does not concur with the audit findings and believes
that the suggested amount of potential Medi-Cal disallowances are inaccurate. However,
even if the audit findings with respect to the Department of Human Services Medi-Cal billings
were infallible, the total amount of suggested disallowance represents approximately one-
quarter of 1% of the Department of Human Services annual budget.
In addition, the 2006-07 Grand Jury Wraparound Program Audit acknowledged improvements
in the areas of administration and fiscal responsibility under Department of Human Services
management. Although the Wraparound Audit made several suggestions for making the
Wraparound Program a “model” program above and beyond state requirements, the audit
noted that, “The County is operating in compliance with all State mandates pertaining to the
Wraparound program” (El Dorado County Grand Jury 2006-2007, Wraparound Program
Audit, GJ 06-049, Prepared by Harvey M. Rose Associates, LLC, May 2007). In fact, many of
the audit recommendations had been implemented before the audit commenced.
In short, the Board of Supervisors concludes that the Grand Jury’s finding that additional
oversight is required of DHS leadership is unsupported by evidence.
5. During the exit conference, the Auditor presented to DHS a copy of State regulations
pertaining to Targeted Case Management and written comprehensive Individualized
Service Plans. DHS stated they did not know of the regulation, had never received proper
training by the State, and therefore, did not comply with the regulation.
Response to Finding 6: The respondent disagrees with the finding. As indicated in Appendix
A, the auditor did not present a copy of this document to Department of Human Services staff,
but rather briefly displayed his copy of what he said were regulations. No statement by
Department of Human Services staff was made to the effect that they did not know of the
regulation, had never received proper training by the State, and therefore, did not comply with
the regulation. The perception that staff failed to comply with “state regulations” suggests an
insufficient understanding of the complexities of the state and federal regulatory environment.
The Board of Supervisors notes that the Department of Human Services analyst who has
administered the Targeted Case Management Program for the County for the past seven years
is considered by the State to be an expert in TCM administration, has collaborated with the
California Department of Health Care Services to present statewide TCM trainings, and serves
as a resource for ongoing technical assistance relative to the operation of TCM programs
statewide.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
RECOMMENDATIONS
1. The Grand Jury agrees with the Audit findings and urges the Board of Supervisors to direct
management in the Departments of Human Services and Mental Health to implement all
the audit recommendations.
Response to Recommendation 1: The recommendation will not be implemented because it is
not warranted. As stated, the limited data reviewed and sampling methodology utilized does
not support the findings of the audit. The Board of Supervisors recognizes that regardless of
the quantitative findings of the audit, some of the recommendations are rather obvious
suggestions for the Department of Human Services and Department of Mental Health
Management. As evidenced from the departmental responses to the audit, the Board
determines that no additional direction is required to Department of Human Services or
Department of Mental Health management.
2. The Board of Supervisors should direct the development of a comprehensive written policy
and procedure for departments on “How To” process requests for confidential records from
auditors and court orders.
Response to Recommendation 2: The recommendation will not be implemented because it is
not reasonable. As the implementers of numerous and disparate state programs, County
departments are accountable not only to the Board of Supervisors but also to a wide range of
state departments with different documentation and access requirements. Consequently, it is
more reasonable and practical to evaluate each request for confidential information in context
than to attempt to establish a “one policy fits all” approach to information requests.
3. Next year’s Grand Jury should determine if DHS provided to the Auditor the documents
requested in the court-order.
Response to Recommendation 3: The Board of Supervisors has no response as this
recommendation is apparently directed at the 2008-09 Grand Jury.
4. Department of Health Services should actively engage in a process with the
State of California to resolve any discrepancies in training when that training conflicts with
statutes and program regulations. Resolutions should be well documented, communicated,
and readily retrievable.
Response to Recommendation 4: The recommendation will not be implemented because it is
not warranted. (The Board of Supervisors notes that the Grand Jury most likely meant this
recommendation for the County Department of Human Services, not the state Department of
Health [Care] Services.) As mentioned in the discussion of the audit findings, the inferences of
the audit are invalid, the County has no history of disallowances suggested by the audit, and
County staff managing particular programs are viewed by the State as experts in the field. In
short, the evidence does not support the conclusion that “discrepancies in training” exist.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
RESPONSES
Response(s) to this report is required in accordance with California Penal Code §933.05.
21
Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
APPENDIX A
El Dorado County Department of Human Services
Response to Grand Jury FY 2007-2008 Final Report
Audit of El Dorado County’s
Medi-Cal Revenues Generated by the
Departments of Human Services
and Mental Health
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15 After a thorough analysis, the 2007-2008 The meaning and intent of the term “questionable” are not
Grand Jury voted to resume the audit with clear. DHS programs are operated under State authority
Harvey Rose Associates, LLC, adjusting the pursuant to the appropriate State and Federal laws,
audit scope to include questionable programs regulations and guidelines. DHS was not made aware of
in DHS and Mental Health Departments. the referenced analysis or given an opportunity to respond.
16 Finding 1. El Dorado County faces a severe DHS disagrees with this finding.
budget crisis and the findings in the Audit The audit implies that the $541,420 is attributable to the
Report provide evidence that the County could Public Guardian Program. As demonstrated by tables
be at risk of losing up to $541,420. If the State contained within the Audit Report, the majority of the
requested the money be refunded, it would amount claimed to be at risk ($393,673) is attributable to
have to come from the County’s general fund. Mental Health programs, with $147,747 attributed to DHS,
The potential losses are due to administrative of which $144,828 is attributed to Public Guardian and
errors and omissions, poor policy $2,919 to Linkages.
communications and procedures, and
The Audit Report identified the scope of the audit as being
questionable management in the Human
the TCM Program, yet the finding implies that the Public
Services Public Guardian Program.
Guardian Program as a whole suffers from questionable
Conversely, the Human Services Linkages
management. The Public Guardian Program Manager and
Program was found to be well managed.
any Deputy Public Guardians or Program Assistants within
Public Guardian Program were not interviewed during this
audit.
Calculations and methodology substantiating the total
possible disallowances are not provided in the Audit
Report. DHS disagrees with the audit as to the total
number of non-compliant TCM encounters and the
potential risk.
The TCM Program and the Public Guardian Program are
separate and distinct programs. The relevance of TCM
audit findings to the operations of the Public Guardian’s
Program has not been articulated in the audit, nor are any
facts supporting the claim of “questionable” management
provided in the Grand Jury’s report.
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16 Finding 3. The Grand Jury and the Auditor The opportunity to review the subject records onsite at
encountered multiple impediments in DHS with very limited redactions (e.g., name and Social
obtaining the necessary legally authorized and Security Number) was available to the Auditor throughout
court-ordered records from DHS. Even with the course of the audit. Based on early communications
repeated County Counsel intervention, the with HMR, DHS expected that HMR would perform an
Auditor, with the court-order, did not receive on-site case file review. In a phone conversation on
requested client case record information, February 11, 2008 between DHS Department Analyst
including requested assessments in effect Yasmin Hichborn and Monica Na of HMR, it was
during the review period, pertinent to the discussed that client files would be available on site for
performance of a comprehensive compliance review but that any documentation leaving DHS offices
audit. Only during the June 9, 2008 exit would be redacted. On February 13, 2008, Ms. Na
conference, did DHS acquiesce to allow the corresponded with DHS by email and indicated that they
Auditor and grand jurors a chance to would begin on-site records inspection on February 15,
physically inspect the records, just six days 2008. As of February 13, 2008, the required court order
before the audit was to be submitted to the had not been issued, and the Auditor was notified that
Grand Jury. The Auditor gave DHS every County Counsel had advised that DHS would be unable to
possible opportunity to comply. After the exit release records without it. The required court order was
conference, DHS did provide the Auditor with not issued until February 20, 2008. The Auditor went
additional information requested. A forward with their planned February 15, 2008 site visit, but
subsequent letter from the Assistant Director did not schedule any visits after receipt of the court order
of DHS to the Grand Jury dated June 13, 2008, allowing on-site inspection of the records, instead choosing
extended a late invitation encouraging jurors to receive records by mail.
to review the electronic records. The invitation On April 14, 2008, DHS staff received an email from the
was received in the Grand Jury after the audit Auditor stating “I think we have everything from the
review period and the closure of the request list now”.
investigation.
Despite ongoing communication between the Auditor and
DHS relative to issues such as clarification of information
and requests for additional information, DHS was not
informed that the level of redaction in the documents was
an impediment to the Auditor’s review. DHS’s first
awareness of the Auditor’s concerns about redaction was
upon receipt and review of the draft Audit Report
(received by DHS after 5:00 pm on Friday, May 30, 2008).
During the June 9, 2008 exit conference, in a good faith
effort to assist the Auditor, DHS offered the Auditor and
representatives of the Grand Jury the opportunity to review
the records in question on-site to confirm that the correct
records had been provided. The offer was declined.
On June 13, 2008, the Assistant Director of DHS followed
up with a written offer for members of the Grand Jury to
make an on-site inspection of the records, but did not
receive a response.
16 Finding 4. The results of the investigation and Department of Human Services welcomes and appreciates
information from previous Grand Juries Board of Supervisors oversight. However, a careful
indicate that closer oversight of the leadership review of recent Grand Jury reports and responses to those
in the DHS by the Board of Supervisors is reports will confirm that DHS is in compliance with State
required. laws and that numerous deficiencies existed in prior audit
work performed by or on behalf of the Grand Jury.
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16 Finding 5. During the exit conference, the DHS disagrees with this finding. The auditor did not
Auditor presented to DHS a copy of State present a copy of this document to DHS, but rather briefly
regulations pertaining to Targeted Case displayed his copy of what he stated were regulations.
Management and written comprehensive No statement by DHS staff was made to the effect that
Individualized Service Plans. DHS stated they they did not know of the regulation, had never received
did not know of the regulation, had never proper training by the State, and therefore, did not comply
received proper training by the State, and with the regulation. In fact, DHS staff informed the
therefore, did not comply with the regulation. auditor that they had attended Statewide TCM training for
Public Guardian providers, that DHS had assisted in the
development of the State-accepted forms used during the
training, and that DHS staff assisted in training
representatives from other Public Guardian offices.
17 Recommendation 4. Department of Health The intent of this recommendation is unclear. There is no
Services should actively engage in a process “Department of Health Services” in El Dorado County.
with the State of California to resolve any DHS works closely with the State throughout the year.
discrepancies in training when that training However, it should be noted that DHS has no authority to
conflicts with statutes and program require any action on the part of the State.
regulations. Resolutions should be well
documented, communicated, and readily
retrievable.
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Cover We found that, to varying degrees, While DHS welcomes opportunities to improve program
Letter opportunities for improvement exist in the performance, the audit lacked sufficient specificity for the
program areas reviewed for improved Department to identify or develop such improvements. The
compliance with Medi-Cal and Targeted DHS audit was specific to TCM. The audit appears to have
Case Management documentation focused on an attempt to determine the potential risk for
requirements to ensure that the County reimbursement disallowances rather than on maximizing
maximizes its Medi-Cal revenues and revenues. DHS disagrees with the audit calculations relative to
minimizes Medi-Cal reimbursements potential disallowances.
disallowances.
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E-4 4.1 Direct Public Guardian Office This statement is recommending the development of policies
management to establish written policies and procedures for a discontinued program funding source.
and procedures and documentation The State suspended billing for TCM services by Public
requirements that are consistent with Guardian offices Statewide effective March 3, 2008. If billing
Targeted Case Management program for TCM services for Public Guardian Programs is reinstated
requirements and regulations, to include: by the State, the State will issue necessary instructions to the
inclusion in Individual Client Services counties.
Plans of client issues identified in In a letter dated April 7, 2008, DHCS notified TCM providers
Assessments; inclusion of specific actions that as of March 3, 2008, TCM providers may not submit
and services in Individual Client Services invoices to DHCS for TCM services performed by staff of
Plans; and, specific discussion in Periodic Public Guardian agencies. This letter is posted on the State’s
Reviews of client progress in meeting TCM website under the heading “Policy & Legislation” as
service objectives and needs identified in “End of TCM Claiming from AP and PG Agencies”.1
previous Assessments and Service Plans.
The Auditor and representatives of the Grand Jury were
19 The Targeted Case Management (TCM) informed of this development by DHS staff during the June 9,
program was recommended for more 2008 exit conference, at which time the Auditor acknowledged
detailed review by the auditors and that he was aware at the time his “risk criteria” was developed
approved by the Grand Jury based on this that TCM funding would likely be terminated for Public
risk criteria. Guardian Programs Statewide. The Auditor’s recommendation
to the Grand Jury was for review of a program that had a high
probability of not being a viable future funding source for the
County. Therefore, the audit of TCM in relation to Public
Guardian services could be expected to be of limited benefit to
the County, the Department and the community. By the time
the draft Audit Report was provided to DHS, TCM was a
discontinued revenue source for Public Guardian Programs
Statewide. Neither the draft nor the final Audit Report
disclosed this relevant information.
E-4 4.2 Direct Linkages program management
to direct staff to include frequency and The recommendation has been implemented.
duration of activities and services in their
Individual Client Services Plans.
DHS has issued an instruction to Linkages staff to include
28 Though a TCM program requirement, frequency and duration on the form where the specific activity
none of the Plans in the twelve sets of case or service is documented.
records reviewed identified the frequency
or duration of the proposed actions to be
taken.
32-33 Exhibit 4.6
Review of 10 Individual Client Service
Plans
Linkages Program
Plans with activity frequency, duration
-------
they were found not fully compliant with
TCM regulations in that none of the
Service Plans reviewed described the
frequency or nature of the activities and
specific services to be performed, as
required by TCM regulations.
1
http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx.
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E-4 4.3 Direct the Department’s TCM The recommendation will not be implemented because it is not
Coordinator to conduct periodic spot warranted. DHS created an audit tool and audits have been
audits of Public Guardian and Linkages performed. A more regular audit schedule has been
program Medi-Cal beneficiary client case implemented for TCM services provided by Linkages and for
records to ensure that they are compliant those TCM services that have not yet been billed for Public
with TCM requirements and report the Guardian.
results in writing to the Director every six However, it is important to clarify that not all Medi-Cal
months. beneficiaries are eligible for TCM services, so an internal audit
of Medi-Cal beneficiary files by the TCM department
coordinator is not warranted unless they also receive TCM
services.
E-4 4.4 Establish protocols for periodic
reviews and audits of TCM and other
Medi-Cal program case records by
oversight agents such as the County
Auditor-Controller, the Chief
Administrative Officer and future Grand
Juries that will allow for unimpaired audits
of Medi-Cal programs by providing all
documents needed to assess program
compliance while still protecting client The State has the ability to review the TCM records at any
privacy. time because these are State records. The relevant records may
25 According to DHS, these impairments also be reviewed by the County’s CAO and the Auditor-
would not occur if the State were to audit Controller’s office. Requests for access by the Grand Jury will
TCM program records since they would be continue to require County Counsel review and approval
entitled to review all aspects of case and/or instruction from the State.
records and records. However, a system
should be established so that other parties
with an interest in County Medi-Cal
revenues, such as the Chief
Administrator’s Office, the Auditor-
Controller or future Grand Juries, can audit
these records without these impairments
and still protect the confidentiality of the
clients.
i Interviews were conducted with directors, DHS notes that “key” staff interviewed at the Department of
program managers and key staff at the Human Services did not include the Public Guardian Program
Department of Human Services and the Manager, Deputy Public Guardians or Program Assistants for
Department of Mental Health. the Public Guardian Program.
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ii Due to the Department of Human DHS is required by law to protect records from access by
Services’ refusal to provide access to unauthorized individuals or entities. On June 21, 2007, the
Targeted Case Management case records State provided DHS with a letter specifying the legal
due to concerns about client requirements for protecting client records. The letter states:
confidentiality, it was necessary for a court These records are governed by Welfare and
order to be obtained to allow access to the Institutions Code section 14100.2, which states that
records for audit purposes. records about Medi-Cal beneficiaries may only be
25 Two other impairments affected this TCM used or disclosed for purposes directly connected with
case file review. First was the extensive the operation of the Medi-Cal program. We would
redacting of the case file documents by not consider a disclosure to the grand jury to be
DHS to the extent that compliance with directly connected with the operation of the program
some TCM program regulations could not and, furthermore, as your letter indicates, a grand jury
be determined. has no authority to investigate a state agency.
The letter also states in regard to Medi-Cal records, that if the
Grand Jury were investigating billing fraud, “Welfare and
Institutions Code section 14100.2 and federal Medicaid
regulations would prevent their release without a court order.
The agency would likely oppose such an order on the ground
that the grand jury auditor has no authority to investigate a
state agency.”
DHS could not release Medi-Cal records, including TCM
records, to the Grand Jury or the Auditor given the specific
direction from the State of California.
The Auditor was informed during the initial conference on
January 25, 2008, that in accord with State guidance, a court
order would be required to comply with the Grand Jury’s
request for records. DHS and HMR mutually developed and
agreed upon the terms memorialized in the February 18, 2008
letter upon which the February 20, 2008 court order was based.
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ii All records provided by the Department The request letter from HMR referenced by the court order
were to have client information such as stated:
name and Social Security number redacted “It was also agreed that identifying client information
though a unique identification number such as names and full Social Security numbers will be
from each client’s records was to remain redacted from the selected documents, though a unique
visible in the records so that it could be identification number from each client’s records will be
matched to a corresponding client master provided on the anonymous client master list provided
list to ensure that we were provided the by the Department so that the [sic] we can verify that
randomly selected case records. we have received the records of the clients selected
ii The required unique identification from the master lists.”
numbers were not included in the The letter attached to the court order stated that a master list
computer generated records as requested would be provided with the unique identification number. It
but were instead handwritten on each did not state that a “unique identification number from each
document. This reduced the assurance that client’s records was to remain visible in the records”.
the auditors received the randomly HMR’s letter formed the basis for the court order. It was
selected records requested. agreed that full Social Security numbers would not be
20 This audit of Targeted Case Management provided. Other than Social Security numbers, no unique
program Medi-Cal billing records was identifying number is common to the Department’s client
impaired by the documentation provided records and the State’s TCM billing records. Even Social
by the Department of Human Services in Security numbers do not appear on every type of document
that: 1) the case file documents provided that was requested for review. Thus, a hand-written key was
could not be positively identified as those developed to facilitate client identification.
of the clients randomly selected for review The only way to relate Departmental records to State TCM
because client identification numbers from records was to add handwritten unique identifying numbers to
the Department’s client master lists were each page. This is because the State TCM system assigns
blacked out by the Department on case file random numbers to each encounter. These numbers cannot be
documents and replaced with handwritten duplicated or overridden at the county level.
numbers; 2) documentation provided did The Department complied with the court order.
not allow for verification of whether or not
claims were submitted for Medi-Cal
reimbursement for the cases reviewed;
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25 To avoid providing documents with client
names, the Department of Human Services
provided clients lists for sample selection
with client identification numbers only.
Consistent with the terms of the February
20, 2008 court order issued requiring the
Department to provide the records
reviewed, a request was made by the
auditors that the identification numbers on
the Department’s client master list be
visible in the case file documents to verify
that the client billing records provided by
the Department were in fact those of the
randomly selected clients. This intended
method of validating that the selected
records were the actual records provided
was not possible as the Department
blacked out the client identification
numbers in the case file documents and
handwrote the identification numbers on
each document. As a result, it cannot be
confirmed that the selected records were
the ones provided by the Department.
Another impairment to the audit process
was that it was not possible to validate that
the selected records contained client
encounters for which the Department
billed Medi-Cal. A request was made for
documentation showing a cross-reference
such as the client identification number of
the reviewed records on the invoice but
this was not provided by the Department.
As a result, it was not possible to verify
which encounters reviewed were billed to
Medi-Cal.
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ii The arrangement in the court order did In addition to State and federal law, DHS is bound by the
allow for provision of the needed records terms of the contract between DHCS and El Dorado County.
but the extent of Departmental redaction Exhibit G to the contract states in part:
efforts exceeded name and Social Security “Protected Health Information” or “PHI” means any
number. Much of the content of progress information, whether oral or recorded in any form or
reports and client service plans was medium that relates to the past, present, or future
blacked out, reducing the extent to which physical or mental condition of an individual, the
case record compliance with all Targeted provision of health and dental care to an individual, or
Case Management requirements could be the past, present, or future payment for the provision
evaluated. of health and dental care to an individual; and that
identifies the individual or with respect to which there
is a reasonable basis to believe the information can be
used to identify the individual. PHI shall have the
meaning given to such term under HIPAA and
HIPAA regulations, as the same may be amended
from time to time.”
Exhibit G further provides that, “Except as otherwise indicated
in this Addendum, Business Associate may use or disclose PHI
only to perform functions, activities or services specified in
this Agreement, for, or on behalf of CDHS 2, provided that such
use or disclosure would not violate the HIPAA regulations, if
done by CDHS.”
Examples of personal identifying information that must be
protected are provided in Welfare and Institutions Code
section 14100.2(b) as “names and addresses, medical services
provided, social and economic conditions or circumstances,
agency evaluation of personal information, and medical data,
including diagnosis and past history of disease or disability.”
Other relevant State and Federal laws may require additional
protections (e.g., HIPAA).
Additionally, Title 42, United States Code, Section
1396a(a)(7) requires agencies to provide “safeguards that
restrict the use or disclosure of information concerning
applicants and beneficiaries to purposes directly connected
with the administration of the state Medicaid program.”
Confidentiality policies governing Medi-Cal and the Medi-Cal
Eligibility Data System (MEDS) are discussed in greater detail
in DHCS All County Welfare Directors Letter 08-04.
Given the need to comply with the relevant State and federal
laws, the court order did not limit redaction to names and
Social Security numbers. HMR staff were informed that
records leaving the office would be subject to much more
extensive redaction than records examined in an on-site
review.
2
CDHS refers to the California Department of Health Services, now the California Department of Health Care
Services (DHCS).
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ii In spite of this impediment, it was still
possible to determine compliance with
most program requirements. “Most” could mean anything from 51% to 99%. That is too
26 In spite of that, it was still possible to large of a range for DHS to be comfortable with as a measure
determine in the majority of cases whether of program compliance, either favorable or unfavorable.
or not the Periodic Reviews were
compliant with most TCM requirements.
ii-iii Initially all Targeted Case Management
records provided by the Department of
Human Services had supervisor signatures
redacted so it was not possible to
determine if the Department was
complying with the Program requirement
that supervisors sign Client Service Plans. DHS offered these records after reviewing the draft Audit
After the exit conference with the Report, learning there was an issue, and determining the
Department, a subsequent set of records information was not protected.
was provided showing the signatures.
20 3) case file documents were so extensively
redacted in some cases that it was not
On April 14, 2008, DHS staff received an email from the
possible to verify compliance with some
Auditor stating “I think we have everything from the request
program regulations;
list now”.
26 Some measures of compliance were Despite ongoing communication between the Auditor and
difficult to determine since so much of the DHS relative to issues such as clarification of information and
content of the records provided was requests for additional information, DHS was not informed
redacted by the Department of Human that the level of redaction in the documents was an impediment
Services. For example, Periodic Reviews to the Auditor’s review.
are supposed to assess accomplishment of
DHS first became aware of the Auditor’s concerns about
the objectives set forth in Individual Client
redaction upon receipt and review of the draft Audit Report.
Service Plans. Unfortunately, much of the
text in the Periodic Reviews and The opportunity to review the subject records onsite at DHS
Individual Client Service Plan documents with very limited redactions (e.g., name and Social Security
was blacked out by DHS to the point that it Number) was available to the Auditor throughout the course of
could not be determined in all cases what the audit.
services or service objectives were being
discussed. In spite of that, it was still
possible to determine in the majority of
cases whether or not the Periodic Reviews
were compliant with most TCM
requirements.
29 None of the recorded Linkage and
Consultation services reviewed were fully
compliant with TCM requirements. In all
cases, there were either no service referrals
or, if there were, the nature of the services
could not be confirmed because so much
of the text in the report was blacked out by
DHS.
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34 Exhibit 4.7
Periodic Reviews in 10 Sets of Case
Records
Linkages Program
# assessing Service Plan objectives
accomplished?
6 Could not be determined due to state of
records
1817 The primary objective of the This statement does not fully incorporate relevant aspects of
Multipurpose Senior Services Program said document, resulting in a misrepresentation of facts. The
(MSSP) is “to avoid, delay, or remedy the referenced document states:
inappropriate placement of persons in “The primary objective of MSSP is to avoid
nursing facilities, while fostering delay, or remedy the inappropriate
independent living in the community. placement of persons in nursing facilities,
MSSP provides services [that] enable while fostering independent living in the
clients to remain in or return to their community. MSSP provides services to
homes”.1 eligible clients and their families to enable
1
California Department of Aging, clients to remain in or return to their homes”
Multipurpose Senior Services Program The Department notes that the currently applicable version of
Site Manual, 1-1, April 2004. the page 1-1 of the MSSP Site Manual is September 2005.
18 Targeted Case Management (TCM) This statement does not fully incorporate relevant aspects of
consists of case management services that said document, resulting in a misrepresentation of facts. The
assist Medi-Cal beneficiaries gain access referenced document states:
to needed medical, social, educational, “TCM consists of case management services that
and other services. The objective of the assist Medi-Cal eligible individuals within a specific
program is to ensure that the changing targeted population to gain access to needed medical,
needs of Medi-Cal eligible individuals are social, educational and other services.” 3
addressed on an ongoing basis and
The goal of TCM is actually identified as:
choices are made from the widest array of
options for meeting those needs.2 “Ensure that the changing needs of Medi-Cal eligible
2 persons are addressed on an ongoing basis and
State Department of Health Care
appropriate choices are provided among the widest
Services, “Targeted Case Management:
array of options for meeting those needs.”
Fact Sheet.” Available for
download at http://www.dhcs.ca.gov
3
State Department of Health Care Services, “Targeted Case Management Fact Sheet.” Available for download at
http://www.dhcs.ca.gov/provgovpart/Documents/ACLSS/TCM/TCMFactSheet.pdf.
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18 The Public Guardian provides services The audit description of the Public Guardian services
that are contingent upon the Office’s paraphrased from the County’s webpage omits that services
appointment as conservator for an provided by the Public Guardian Program are “defined and
individual by the Superior Court or directed by the Probate Division of the Superior Court”.
through its Representative Payee program In critiquing Public Guardian TCM services, the audit does not
for individuals who receive income address the differences between the target populations served
through public entitlements, public by the Public Guardian, those being probate conservatees, LPS
benefits programs or other benefits conservatees and representative payee clients. This is an
programs and voluntarily seek financial important differentiation on many levels, specifically the nature
management services. of the services provided, program service and oversight
responsibilities and, most relevant, the level and type of
decision-making authority delegated to the Public Guardian for
the three divergent client populations.
The representative payee program consists primarily of services
to those individuals who are required by the Social Security
Administration to have a representative payee. The voluntary
component is that the SSA benefit recipient may choose a
representative payee, provided that person or organization
meets SSA’s requirements.
Given that 58.3% of the clients selected by the Auditor were
representative payees, DHS would expect a statistically
significant impact on the results of the audit. While financial
management is mandatory, provision of TCM services requires
the cooperation of the client. Representative payee clients
participate in TCM services but may (and often do) decline
specific services. Representative payees have the right to
refuse Public Guardian referrals and assistance with any matter
that is not financial in nature.
18 The Linkages program offers case This statement does not fully incorporate relevant aspects of
management services and referral to…4 said document, resulting in a misrepresentation of facts. The
[Emphasis added.] referenced document states:
4
The Linkages program description is “care management as well as information and
posted on the Department’s website at assistance regarding appropriate community
http://www.co.eldorado. resources…”. [Emphasis added.]
ca.us/humanservices/Linkages.html This website further states that “Linkages care managers work
with you, your family, and other community agencies to
provide essential links that help you live independently in your
own home”.4
4
http://www.co.el-dorado.ca.us/humanservices/Linkages.html.
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19 The Targeted Case Management (TCM) In a letter dated April 7, 2008, DHCS notified TCM providers
program was recommended for more that as of March 3, 2008, TCM providers may not submit
detailed review by the auditors and invoices to DHCS for TCM services performed by staff of
approved by the Grand Jury based on this Public Guardian agencies. This letter is posted on the State’s
risk criteria. TCM website under the heading “Policy & Legislation” as
“End of TCM Claiming from AP and PG Agencies”. 5
The Auditor and representatives of the Grand Jury were
informed of this development by DHS staff during the June 9,
2008 exit conference, at which time the Auditor acknowledged
that he was aware at the time his “risk criteria” was developed
that TCM funding would likely be terminated for Public
Guardian Programs Statewide. The Auditor’s recommendation
to the Grand Jury was for review of a program that had a high
probability of not being a viable future funding source for the
County. Therefore, the audit of TCM in relation to Public
Guardian services could be expected to be of limited benefit to
the County, the Department and the community. By the time of
the draft Audit Report was provided to DHS, TCM was a
discontinued revenue source for Public Guardian Programs
Statewide. Neither the draft nor the final Audit Report
disclosed this relevant information.
19 And unlike the Multipurpose Senior The State conducted a desk review of the El Dorado County
Services Program, TCM has never been TCM Program in 2002. No adverse findings were
audited. communicated to DHS as a result of this desk review.
State audits of 13 of the 49 counties that participate in TCM
resulted in the issuance of Policy and Procedure Letter PPL 03-
003. The State identified issues “that may prove useful when
conducting internal reviews” and help the counties “maintain
an accountable and effective program.” DHS has applied the
information provided by the State to its internal review process.
19 The Program Manager who oversees the The person who oversees the TCM reimbursement claiming
TCM and MAA program reimbursement process is actually a Department Analyst, not a Program
claiming processes reviews encounter Manager.
progress notes before invoicing the State An internal review of TCM encounters is conducted monthly
for reimbursement, but does not review by the Analyst. The internal review determines which
client files for overall compliance with encounters meet TCM requirements and will be submitted for
program requirements. For example, reimbursement.
although the progress notes for encounters
TCM does not require annual re-assessments. Re-assessments
may be reviewed discretely, the entire
on an annual basis are a California Department of Aging
client file may not reviewed as a whole,
program requirement; annual re-assessments are not a TCM
and items that are required of the client
compliance requirement.
file, such as annual Assessments may not
be checked for compliance.
5
http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx.
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20 The Public Guardian provides services that Given that 58.3% of the clients selected by the Auditor were
are contingent upon the Office’s representative payees, DHS would expect a statistically
appointment as conservator for an significant impact on the results of the audit. While financial
individual by the Superior Court or management is mandatory, provision of TCM services requires
through its Representative Payee program the cooperation of the client. Representative payee clients
for individuals who receive income participate in TCM services but may (and often do) decline
through public entitlements, public specific services. Representative payees have the right to
benefits programs or other benefits refuse Public Guardian referrals and assistance with any matter
programs and voluntarily seek financial that is not financial in nature.
management services.
19 For example, although the progress notes
for encounters may be reviewed discretely,
the entire client file may not reviewed as a
whole, and items that are required of the
client file, such as annual Assessments
may not be checked for compliance.
TCM does not require re-assessments. Re-assessments on an
26 The Assessment documentation provided
annual basis are a California Department of Aging program
by DHS for all but one of the twelve
requirement for the Linkages Program (not the Public
Public Guardian clients reviewed were Re-
Guardian Program). The audit uses the term “re-assessment”
assessments rather than the requested
to refer to TCM documents that are not utilized by, and are not
clients Assessments in effect for the period
required to be utilized by, Public Guardian.
being reviewed.
27 The Public Guardian’s Re-assessment
form contains only four categories: 1)
Medical/Mental; 2) Social/Environmental;
3) Financial; and 4) Closing (for
comments and summary statements).
20 Most of the Targeted Case Management Due to limitations in the data reviewed, DHS disagrees with
records reviewed for Public Guardian the conclusion that most of the TCM records reviewed for
clients were found non-compliant with one Public Guardian were found non-compliant.
or more aspects of Program regulations. If
this pattern holds true for all Public
Guardian clients, a good portion of the
Department’s Medi-Cal revenues for this
program are at risk of being disallowed for
non-compliance with Targeted Case
Management regulations.
20 On the other hand, records reviewed for TCM regulations do not specify documentation formats or type
Linkages program clients were found to be of forms. Linkages documentation conforms to the
substantially compliant. These records requirements of the California Department of Aging.
were more thorough and structured
consistent with Targeted Case
Management requirements. Some areas of
the Linkages program billing records,
however, were found to be noncompliant
with program requirements or
determinations of compliance could not be
made because of the form in which case
file records were provided by DHS.
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20 Assessment and Individual Client Service
Plan documents provided by the
Department for a number of clients were
prepared after the Periodic Reviews
provided so it was not possible to
determine if service plans and objectives
in effect at the time of the Periodic
Reviews had been assessed by the case
managers.
It is true that some of the documents submitted were
25 The second other impairment was that the inadvertently for the most current date and not the encounter
Assessment and Individual Client Service date. The Auditor did not communicate to DHS management
Plan documents provided for some of the that this was a barrier or work towards resolving the issue.
case records were prepared after the
Periodic Review documents provided
though the request was made for
Assessments and Client Service Plans in
effect during the review period for each
client.
33 Some of the Service Plans provided by
DHS were those prepared after the 13
month review period for the case records.
20 Given the rate of non-compliance found The Audit Report does not provide the calculations or define
with the sample Targeted Case the methodology substantiating the possible disallowances.
Management records reviewed, the DHS disagrees with the audit as to the total number of non-
Department of Human Services is at risk compliant TCM encounters and the potential risk of
of Medi-Cal disallowances of up to disallowance.
$147,747 for Fiscal Year 2006-2007 if the DHS agrees that any amount resulting from potential
sample results apply to all Medi-Cal disallowances would be reduced if deficiencies were corrected
beneficiary program clients. To the extent to the State’s satisfaction.
that deficiencies found can be corrected to
the State’s satisfaction, this amount would
be reduced.
22 As of January 2008, the Public Guardian It must be clarified that not all Medi-Cal beneficiaries are
was serving 327 clients, of which 153 eligible for or receive TCM services. As of February 2008
were Medi-Cal beneficiaries. (not January 2008), the Public Guardian was serving 327
clients, of which 206 were Medi-Cal beneficiaries and of those
206, 153 were eligible for TCM services.
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23 1. Needs Assessment. The Assessment It appears this information was extrapolated from the TCM
documents the conditions of the client and Provider Manual. These statements omit consideration or
supports the selection of services for the discussion of relevancy to the individual in assessing the
individual. The Assessment should contain client’s needs.
at least the following elements: 1) The more detailed discussion of the Assessment within the
medical/mental health; 2) training; 3) TCM Provider Manual states:
vocational needs; 4) social/emotional
“The documented assessment identifies the
issues; 5) housing/physical needs; 6)
beneficiary's needs. The assessment
family/social matters; and, 7) finances.
supports the selection of activities and
26 The purpose of the required TCM assistance necessary to meet the
Assessment is to document the client’s beneficiary’s assessed needs and must
needs in the following areas: 1) include the following, as relevant to each
Medical/Mental Health; 2) Training needs individual:
for community living; 3) • Medical/mental condition. The
Vocational/Education needs; 4) Physical assessment may require obtaining
needs, such as food and clothing; 5) evaluations completed by other providers
Social/Emotional status; 5) of service.
Housing/Physical environment; and, 6) • Training needs for community living.
Family/Social Support systems. • Vocational/educational needs.
27 The Public Guardian’s Re-assessment • Physical needs, such as food and
form contains only four categories: 1) clothing.
Medical/Mental; 2) Social/Environmental; • Social/emotional status.
3) Financial; and 4) Closing (for • Housing/physical environment.
comments and summary statements). • Familial/social support system.6
While some of the other elements required [Emphasis added.]
for TCM Assessments are embedded in the For example, a 90-year old assisted living facility resident is
four Re-assessment categories (e.g., unlikely to require a vocational needs assessment. Conversely,
Family/Social Support Systems is a a mentally retarded 19 year old representative payee living
subsection of the Social/Environmental with his or her parents would be unlikely to need a housing
category) or may be addressed in summary assessment.
written comments, some of the TCM At the time a Periodic Review is performed, the Public
required elements such as Training or Guardian case worker prepares an updated Service Plan, even
Vocational/Education needs are simply not if there are no changes to the previous Service Plan. This
included and could potentially go prompts the case manager to address 19 distinct areas
unaddressed in Re-assessments. The identified on the form to be assessed in terms of meeting the
Public Guardian could ensure greater client’s needs.
compliance with TCM Assessment
requirements and greater continuity in
client services by revising its Re-
assessment standardized forms to include
all required Assessment elements.
6
TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-1.
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23 3. Periodic review. This is an evaluation of
the beneficiary’s progress toward
achieving goals in Individual Client
Service Plans must be assessed at least
every six months. The Linkages program
requires periodic review at least every 3
months.
24 TCM requirements are for Periodic
Reviews at least every six months for the
Public Guardian and every three months
for the Linkages program.
It appears these statements were paraphrased from the TCM
31 The TCM service components and Provider Manual. However, the statements do not fully
requirements for the Linkages program is incorporate relevant elements of said document, resulting in a
the same as for the Public Guardian with misrepresentation of said facts. The referenced document
the exception that Periodic Reviews must actually states:
take place at least every three months “The case manager must periodically
instead of the Public Guardian requirement reevaluate the beneficiary's progress toward
of every six months. achieving the objectives identified in the
33 Though TCM regulations require Periodic service plan to determine whether current
Reviews of program clients at least every services should be continued, modified, or
six months, the Linkages program has a discontinued. The review shall be:
more restrictive requirement that Periodic • Completed at least every six months” 7
Reviews take place at least every three [Emphasis added.]
months. There is a separate California Department of Aging
33 As shown in Exhibit 4.7, the majority of requirement for the Linkages Program that a face-to-face
Linkages Program Period Reviews were contact with the client must occur every three months. This is
conducted within the required three month a Linkages requirement, not a TCM requirement. 8
interval requirement.
34 While the case records reviewed showed
that most Linkages clients do receive visits
from the case managers more frequently
than the minimum required four times a
year, the fact that certain Linkage and
Consultation services are not documented
as such has resulted in an absence of TCM
required 30 day follow-ups to such
services.
7
TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-2.
8
Linkages Program Manual, Section 7.E., Monitoring and Follow-Up, page 23.
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Twenty Medi-Cal eligible clients were The cut-off date was actually July 2007, not August 2007.
randomly selected for review from the Documentation was not submitted for 8 clients because: 4 had
Public Guardian’s client list. DHS did not not received TCM services prior to July 2007, 3 had not
submit documentation for eight of the 20 received billable TCM services within the 13 month time
requested sets of records for the following frame, and 1 client was erroneously included in the sample list.
stated reasons: three had billings after the The Auditor did not request additional client records to bring
August 2007 cutoff date, two were the sample size back up to 20.
erroneously attributed to the program
sample and three had not received
services. Consequently, twelve of the
twenty requested Public Guardian Medi-
Cal beneficiary client case records were
reviewed.
26 A minority of the twelve randomly DHS disagrees that records that are fully compliant with TCM
selected sets of Public Guardian client Program regulations are at risk for Medi-Cal disallowances.
records reviewed were found to be fully
compliant with TCM program regulations
and are thus at risk for Medi-Cal
disallowance.
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27 The Individual Client Service Plan This statement misquoted the referenced document and did not
documents in the sample client records fully incorporate relevant aspects of said document, resulting
could be characterized more as checklists in a misrepresentation of facts. The referenced document
rather than “written, comprehensive states:
individual service plans”2, as required by “written, comprehensive, individualized
TCM regulations. Instead of writing, many service plan”9
Plans simply contained checked off boxes
All Service Plans are client-specific. The TCM Provider
for “Problems or Service Areas” such as
Manual actually states that the plan will be individualized to
“Financial” with no written commentary or
the client. Therefore, some areas may not require written
specific objectives or actions to be taken.
commentary or specific objectives or actions in need of
Many of the Plans reviewed did not
attention. For example, a 90-year old assisted living facility
identify services the client would be
resident is unlikely to require a vocational needs assessment.
referred to, as required by TCM
Conversely, a mentally retarded 19 year old representative
regulations, or were simply comprised of
payee living with his or her parents would be unlikely to need
notes regarding previous actions taken by
a housing assessment.
the case manager such as, “Deputy Public
Guardian got a temporary card for file.” Checkboxes are a tool used to indicate which areas need
2 attention from the case worker. The Public Guardian case
Targeted Case Management Overview,
manager prepares the Service Plan, which prompts the case
page T-2-1-1, California Department of
manager to consider 19 distinct areas identified on the form to
Health Care Services.
be assessed for meeting the client’s needs. DHS agrees that
case notes regarding actions by the case managers could be
more directly related to the Service Plan areas and has taken
steps to improve both the correlation of the areas and the
review by supervisory staff.
TCM Service Plans do not have a required format. Service
Plans may be designed by each program participating in TCM
using the format that works best for them. Check boxes are an
acceptable method as evidenced by the State’s use of the
forms, which El Dorado County Public Guardian staff
participated in the development of, during a Statewide TCM
training.
In fact, DHS staff informed the Auditor that they had attended
Statewide TCM training for Public Guardian providers, that
DHS had assisted in the development of the State-accepted
forms used during the training, and that DHS staff assisted in
training representatives from other Public Guardian offices.
29 When such services, called Linkage and This statement did not fully incorporate relevant aspects of
Consultation, are provided, TCM said requirements, resulting in a misrepresentation of facts.
regulations require that the initial referral The TCM Provider Manual states:
or consultation be documented and that a
documented follow-up occurs within a “Linkage and Consultation
maximum of 30 days to determine whether TCM services provide beneficiaries with
the services were provided and whether linkage and consultation and with referral to
they met the client’s needs. Linkage and service providers and placement activities. The
Consultation services are not required but case manager shall follow up with the
when they are provided, they must follow beneficiary and/or service provider to
the protocols described. determine whether services were received and
9
TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-1.
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29 Documentation of required 30 day follow- whether the services met the beneficiary’s
ups to the Linkage and Consultation needs. The follow-up shall occur as quickly as
services were not found in any of the indicated by the assessed need, not to exceed
eleven reported incidents. thirty (30) days from the scheduled date of the
referral service.”10 [Emphasis added.]
34 TCM regulations require that referral to
Hence, 30-day follow-ups are only required on referrals with
such services be followed up within 30
specific, scheduled services and must not exceed 30 days from
days to determine if the services were the scheduled date of service. The 30-day follow up is not
received and whether they met the client’s required for referrals with open time frames or for referrals
needs
without a scheduled service.
34 None of the case records in which such
services are recorded contained 30 day
follow-up documentation either.
34 While the case records reviewed showed
that most Linkages clients do receive visits
from the case managers more frequently
than the minimum required four times a
year, the fact that certain Linkage and
Consultation services are not documented
as such has resulted in an absence of TCM
required 30 day follow-ups to such
services.
Since the TCM program has many It is not clear how the Auditor arrived at the opinion that some
requirements, some more significant than TCM requirements are “more significant than others” or how
others, some judgment was necessary to the Auditor defines “substantial compliance”.
define substantial compliance. For The Audit Report acknowledged that the State would likely
example, none of the case records offer the Department an opportunity to correct deficiencies
reviewed for either the Public Guardian or prior to a finding of disallowance. The Department’s
the Linkages program contained the understanding of Medi-Cal programs is that disallowances are
frequency or duration of activities not made unless the work was not performed or a duplication
recommended for clients in the Individual in services is identified.
Client Service Plans, as required by TCM
regulations. Using this measure, all
encounters billed for during preparation of
Client Services Plans are out of
compliance with TCM regulations and are
therefore subject to Medi-Cal
disallowance.
A different standard was used though since
the absence of frequency and duration of
Service Plan activities was not considered
as serious a breach of compliance as, for
example, lack of compliance with the
TCM requirement that a face-to-face
Periodic Review of progress be conducted
with the client at least every six months.
10
TCM Provider Manual, Section 2, Targeted Case Management Program Descriptions, page T.2-1-2.
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36 If a case file was found compliant with all Individual billed encounters do not have to contain all TCM
TCM requirements except including the components. Only those components specific to the TCM
frequency and duration of activities in the encounter being billed are required. Case files typically
Individual Client Service Plan, the file was contain additional information relevant to the TCM encounter.
considered compliant. If a case file was Full case files were not reviewed by HMR nor were they
non-compliant in a variety of areas such requested.
as: not specifying activities for the client in Case file compliance cannot be determined based on the
the Individual Client Service Plan; not limited number of and types of documents reviewed during the
cross-referencing service needs from the Audit.
client’s Assessment in the Individual
Client Service Plan; and, not specifying
the frequency and duration of activities in
the Individual Client Service Plan, the case
file was considered non-compliant and
subject to Medi-Cal disallowance.
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APPENDIX B
El Dorado County Mental Health Department Response to the 2007-08 Grand Jury Final
Report Part 3: Audit of Human Services and Mental Health Medi-Cal Revenues
Case No. GJ 07-006
Response to Grand Jury Audit Recommendations for Mental Health Department
The Mental Health Department commends the 2007-2008 El Dorado County Grand Jury for its
sincere effort to assure the clinical and fiscal integrity of the Department’s Medi-Cal policies.
Although the Department has serious concerns about
1) the statistical legitimacy of generalizations (i.e., extrapolations) inferred from results
based on the invalid audit sample selected by the Jury’s auditor and
2) the multiple discrepancies between the Department’s audits of the same charts analyzed
by the Jury’s auditor
the Department nevertheless completely agrees with the recommendations contained in the
Jury’s report. Specifically:
The Jury’s Recommendations
The Director of the Department of Mental Health should:
1) Direct the Department’s Utilization Management/Quality Improvement Coordinator to
continue to focus Department manager training efforts on ensuring that complete
progress notes, complete assessments and complete client plans are in every case file to
minimize the risk of Medi-Cal disallowances for the Department and that all eligible
services provided are included in Medi-Cal claims.
Response to Recommendation 1: The recommendation has been implemented. The
Department conducts its own internal documentation training program for clinicians and its
own internal medical records’ audits since the beginning of calendar 2006. In addition, the
ongoing conversion to a combined electronic medical record and billing software
application will assure that each billable service documented in the medical record will be
correspondingly billed to Medi-Cal electronically.
2) Direct the Utilization Review Coordinator to include reviews for unbilled services as part
of the Department’s routine Quality Improvement audits and to report the results of these
audits quarterly to the Director.
Response to Recommendation 2: The recommendation has been implemented. The
Department’s internal audit tool routinely identifies delivered services and cross-checks the
billing system to insure that a claim is submitted to Medi-Cal for each billable service
delivered. As the conversion to the new software billing application transpired between
February and August 2007 (coincidentally, the time frame of the Grand Jury’s audit), the
Department was aware that not all billable Medi-Cal services were captured and claimed.
As acknowledged in the auditor’s report, this conversion-related omission has been fully
rectified.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
3) Set goals for each Program Manager that make them accountable for eliminating the
number of potential Medi-Cal disallowances and unbilled services in their program areas,
measurement and achievement of which should be captured through the Department’s
regularly performed Quality Improvement audits.
Response to Recommendation 3: The recommendation has been implemented. The
Department’s internal audit process consists of ongoing, sequential, program-by-program
medical records’ reviews and plans of correction for which each clinical program manager
is responsible. Each program manager’s annual performance evaluation consists of
reviewing the integrity of his or her unit’s Medi-Cal billing errors and successful plans of
correction.
The Board of Supervisors should:
4) Direct the Director of Mental Health to annually report to the Board and Chief
Administrative Officer the results of the Department’s Quality Improvement audits and
success in reducing potential Medi-Cal disallowances and unbilled services.
Response to Recommendation 4: The recommendation has been implemented. This is
accomplished both in the quarterly and annual reporting of the Department’s QI
performance indicators to the CAO’s office and in the annual BOS performance evaluation
of the Department’s Director.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
EL DORADO COUNTY GRAND JURY 2007-2008
El Dorado County Procurement Department
Case No. GJ 07-019
REASON FOR REPORT
The El Dorado County Grand Jury received a complaint regarding poor customer service levels
delivered by the County Procurement and Contracts Division of the Chief Administrative Office
(Purchasing Department). There was sufficient concern to warrant the Grand Jury investigating
the allegations and determining if some corrective recommendations would surface.
BACKGROUND
County Procurement Policy #C-17 states, “The County Purchasing Department is responsible for
the procurement of services, supplies, materials, goods, furnishings, equipment, and other
personal property for the County and its offices unless otherwise excepted by ordinance or these
policies.” The Purchasing Department is also responsible for providing leadership, guidance and
assistance to departments in all procurement related matters, including interpreting and applying
County policies and procedures related to procurement of goods and services. The department is
expected to provide a high degree of customer service.
The Purchasing Department is staffed with seven people: a department manager, three buyers (of
which one position is currently vacant), one analyst (concentrating primarily on contracts), and
two administrative support personnel. This county decentralizes the purchasing function as it
relates to contracts. There are currently seven additional employees engaged in the contract
process within the departments of transportation, environmental health and public health.
METHODOLOGY
The Grand Jury gathered data through interviews with county personnel, as well as reviewing
written county documents.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
El Dorado County Personnel Interviewed:
 Auditor/Controller
 Chief Administrative Officer
 Information Technology Department Manager
 Office of Emergency Services Manager
 Procurement Department Analyst
 Procurement Department Buyer
 Procurement Department Manager
Documents Reviewed:
 Document titled “Procurement and Contracts Division Workflow Analysis and
Recommendations” dated 10-31-2007
 Document titled “Purchasing Issues” from Purchasing/Fiscal Staff
meeting 1-30-2008
 Documented procurement problems from various county sources
 El Dorado County Procurement Policy C-17, adopted 10-11-2006;
revised 3-20-07
 Several papers regarding procurement issues from various County sources
FINDINGS
In accordance with California Penal Code §933 and §933.05, each finding will be responded to
by the government entity to which it is addressed. The responses are to be submitted to the
Presiding Judge of the Superior Court. The 2007-2008 El Dorado County Grand Jury has
arrived at the following findings.
1. Interviews with County personnel indicate a very poor internal and external customer
service level for the purchasing function in the County. This is evidenced by late billings
and payments, as well as excessive time to process contracts and bids.
Response to Finding: The respondent disagrees partially with the finding. Over the
past fourteen (14) months, the Procurement and Contracts Division has worked diligently
to provide a heightened level of service to internal and external customers. Included in
this was the implementation of a Contract Tracking System, Contract Retrieval System,
Bid Tracking System and improved forms which are all available on the County’s
intranet site for use by all internal customers. External customers have been provided
with an enhanced online bid notification system, bid results system, and bid addenda
notification process which are all available on the County’s internet site. Late billings
and payments could occur for a variety of reasons, including delays by the vendor, delays
by the department in submitting claims to the Auditor’s Office and should not be seen as
an indication of quality or level of services provided by the Procurement and Contracts
Division.
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2. A package put together by the Purchasing Department in October of 2007 titled
“Procurement and Contracts Division Workflow Analysis and Recommendations”
(PCDWAR) was reviewed. This document was prepared for the Chief Administrative
Officer (CAO), and some of the recommendations in the document were presented to the
Board of Supervisors (BOS). The main thrust of the recommendations was to increase
staffing levels, with a few substantive process change recommendations. These
recommendations were based on a comparison to Placer County’s procurement processes
and staffing. Comparing El Dorado County to Placer County is not a valid comparison as
Placer County has four additional cities (six vs. two) making Placer County's
procurement functions and needs greatly different.
Response to Finding: The respondent disagrees wholly with the finding. The
“Procurement and Contracts Division Workflow Analysis and Recommendations”
document was prepared by the Procurement and Contracts Division at the request of the
Chief Administrative Officer and a copy was provided to the entire Board of Supervisors
(BOS) on October 31, 2007. While some of the comments in this document did
recommend additional staffing to manage the increased workload and volume, many
additional recommendations were presented that did not include the increase in staffing
levels. The comparison to Placer County is a valid and warranted component to this
report. Despite the fact that Placer County has four (4) additional incorporated cities
results in Placer County’s procurement needs and functions to be quite similar to those
of El Dorado County. This was validated in a meeting with a representative of the
Placer County Procurement Division in the preparation of this work product. However,
this document was not intended to address what is typical in the context of what other
county governments or private industry provide in terms of service levels to user
departments.
3. This PCDWAR package contained detailed process flow charts for each major segment
in the procurement process. The processes are long, complex, and
heavily “paper-based." There are also lead-time charts in the package, but nothing to tell
the reader if these processes and lead times are typical in the context of other county
governments, private industry, or any measure of meeting expected levels of service to
user departments.
Response to Finding: The respondent disagrees partially with the finding. The
referenced PCDWAR package does contain detailed process flow charts for each major
segment of the procurement process. As demonstrated by these flow charts, the
processes are long, fairly complex and are, to a certain extent, “paper based”. The
purpose of the flow charts was to inform the Board and the CAO about processes
currently in place and establish a starting point for improvement. However, this
document was not intended to address what is typical in the context of what other county
governments or private industry provide in terms of service levels to user departments.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
4. The current purchasing process involves a time period for County Counsel and Risk
Management to review all contracts. The lag times built in for those reviews appear
excessive, especially if it is a renewal of an existing contract.
Response to Finding: The respondent partially disagrees with the finding. The
timeframes noted in the PCDWAR with respect to the involvement of County Counsel and
Risk Management are the agreed to timeframes between those departments and those
departments that prepare contracts. Further, County Ordinance 2.06.040 mandates that
any contract not written by County Counsel must be reviewed by County Counsel for
approval as to form.
5. When a purchase order or contract needs to be changed, the current process necessitates
virtually going back to the beginning of the process, adding excessive time delays.
Response to Finding: The respondent agrees with the finding.
6. It is recognized by the purchasing department, and the CAO, that the purchasing data
management system, Advanced Purchasing Inventory Computer System, is out of date
and inadequate to facilitate faster turnaround times for processing change orders.
However, there is no plan or budget to affect an upgrade to this software program.
Response to Finding: The respondent agrees with the finding.
7. Although the problems within the purchasing function are recognized and acknowledged
by both the CAO and the purchasing department, there are no definitive plans to fix the
problems.
Response to Finding: The respondent partially disagrees with the finding. The Chief
Administrative Officer and the Purchasing Division recognize that improvement
opportunities exist within the purchasing function. It is expected that the new Chief
Administrative Officer will monitor the progress of the purchasing function.
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RECOMMENDATION
1. The Grand Jury recommends that a task force be formed comprised of expert end users
and outside vendors, charging them with the responsibility of streamlining the
procurement process and improving the customer service level to all internal departments
and external vendors. This end user task force should include members from all major
County functions. The BOS should champion this process and assign one of the
Supervisors to oversee the progress of this task force, with a monthly update from the
leader of this task force to him/her and the CAO. We recommend that this task force start
with a “blank page,” and identify an appropriate flow process, effective computer
systems’ support and lead times that best serve the needs of the County and outside
vendors. Significant progress has already been made in identifying the current process,
but the challenge to the team is to identify what changes should be made to improve the
procurement process.
Response to Recommendation: The recommendation requires further analysis. The
forming of a task force does have merit. However, more analysis and evaluation of the
most appropriate way to implement this recommendation is necessary. The Chief
Administrative Officer will consider alternatives and strategies to streamline the
procurement process and improve customer service given the overall context of the
county budget and relationship of the CAO Purchasing Division to other county
departments. This may or may not require the convening of a task force. The CAO will
bring the results of this analysis to the Board of Supervisors by December 31, 2008.
2. The completed task force report should be written and submitted to the BOS with all
recommended changes no later than the end of fiscal year 2008-2009.
Response to Recommendation: The recommendation requires further analysis.
Please refer to the response to Recommendation 1 above.
3. No additions to personnel should occur until such time as a full review of the
procurement process is completed.
Response to Recommendation: The recommendation is not warranted. During the
Fiscal Year 2007 - 2008 mid-year budget cuts, two (2) positions in the Procurement and
Contracts Division were eliminated taking the total allocation to a staff of five (5). The
proposed budget for Fiscal Year 2008 - 2009 did not include any additional personnel
allocations to the division. We recognize the reasonableness that refraining from adding
staff to the division prior to the completion of further analysis.
RESPONSES
Response(s) to this report is required in accordance with California Penal Code §933.05.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
EL DORADO COUNTY GRAND JURY 2007-2008
Victim Restitution
GJ 07-014
REASON FOR REPORT
The Grand Jury elected to investigate the County’s Victim Restitution activity to determine if El
Dorado County is effectively and efficiently managing
victim restitution.
BACKGROUND
The successful 1998 ballot initiative, known as the California State Constitutional “Victims’ Bill
of Rights,” created a new Constitutional Right for all victims of crime to receive restitution
from their offender.
“It is the unequivocal intention of the People of the State of California that all
persons who suffer losses as a result of criminal activity shall have the right
to restitution from the persons convicted of crimes for the losses they suffer.”
The State of California Victims Compensation and Governmental Claims Board (VCGC) assists
victims of violent crimes. Victims of non-violent crimes must rely mostly on the County to
assist with ensuring that their right to restitution is realized.
METHODOLOGY
The Grand Jury heard sworn testimony, information gathered from interviews and the review of
documentation consisting of reports, written statements, and observation of court restitution
proceedings.
The investigation focused on:
1. Processes and preparation necessary to attain and amend court orders
of restitution
2. Court ordered restitution collection
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
3. Disbursement of payments
4. Enforcement of the court restitution order including financial reviews when
offenders fail to consistently pay their restitution
Additionally, the investigation reviewed the efficiency and effectiveness of the following
County restitution processes:
 Educating and supporting victims on restitution from the moment the crime is
reported through the life of the restitution order
 Monitoring the offender’s payment progress on existing
restitution orders
 Determining if the County has a centralized and comprehensive county-wide
restitution accounting system
 The collection and administration of restitution including:
a. Administrative fees
b. Financial reviews
c. Fines
d. Interest
e. Restitution orders payable to the victim(s)
 Disbursing restitution to the victim and reimbursement to the California State
VCGC Board
People Interviewed:
 Alameda County Deputy District Attorney Restitution Specialist
 California Department of Corrections and Rehabilitation, Restitution Program
Manager
 El Dorado County:
Assistant Court Executive Officer
Chief Probation Officer and staff members
District Attorney
Fiscal Administrative Manager
Public Defender
Sheriff
Sheriff’s Team of Active Retirees (STAR)
Superior Court Judges
Treasurer-Tax Collector
Victim Witness Program Coordinator
Documents Reviewed:
 Alameda County Restitution Program Policy and Procedures
 Alameda County Superior Courthouse-Oakland Corpus Restitution
Court Calendar
 Applicable California Restitution Statutes
 California Constitution, Victims’ Bill of Rights
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
 California Department of Corrections and Rehabilitation State Restitution
Program Audit from 2002 and 2004
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
 California State Controller’s Audit Report on Alameda Restitution Fines and
Court Ordered Restitution, February 25, 2004
 California Victim Compensation and Governmental Claims Board Restitution
Policy and Procedures
 El Dorado County District Attorney Victim Witness Program, Restitution Policy
and Procedures
 El Dorado County Probation Department Restitution Policy
and Procedures
FINDINGS
1. The County’s Restitution activity process is not centralized.
Response to Finding 1: The respondent agrees with the finding.
2. The County and City jails have no procedure to collect victims’ restitution
from inmates.
Response to Finding 2: The respondent agrees with the finding. However, there is
currently no legal mechanism for jails to collect victim restitution from inmates.
3. There is insufficient follow-up with victims to obtain information as to their actual
losses. This information is necessary to support the issuance of a victim restitution
order by the court. According to the 2002 State Department of Corrections and
Rehabilitation Restitution Audit, approximately 11% of offenders in the California
State Prison system sentenced from El Dorado County have a court order to pay
restitution to the victim(s).
Response to Finding 3: The respondent disagrees partially with the finding. There is
sufficient follow up if the offender is sentenced to formal probation. Insufficient follow up
occurs when the offender is sentenced to summary or informal (unsupervised) probation.
4. Attaining timely victim information, including losses, is essential. The Probation
Department is responsible for determining victim losses if the offender is sentenced to
probation, which may be well after the crime
is reported.
Response to Finding 4: The respondent disagrees partially with the finding. Attaining
timely victim information, including losses, is essential. The Probation Department is
responsible for determining victim losses if the offender is sentenced to formal probation.
However, the Probation Department is not responsible for determining victim losses if the
offender is sentenced to summary or informal probation.
5. The District Attorney’s Office of Victim Services is cognizant of the rights of victims
and provides valuable services to victims of crime in El Dorado County. However,
insufficient funding severely limits the services the District Attorney is able to provide.
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Response to Finding 5: The respondent agrees with the finding.
6. When offenders are sentenced to State prison, or a juvenile facility, all outstanding
restitution ordered for all cases is transferred to the Department of Corrections for
collections. The State of California is only able to disburse 25% of victim restitution
collected to victims because victim information is unavailable. It is imperative that
victim information is included in the case records file accompanying the offender when
sentenced to State prison.
Response to Finding 6: The respondent disagrees partially with the finding. It is true
that when offenders are sentenced to a state prison or juvenile facility all outstanding
restitution ordered for all cases is transferred to the California Department of Corrections
and Rehabilitation for collections. The Board of Supervisors is unable to verify the state’s
disbursement of victim restitution.
7. Although the Probation Department is diligent and successful in their efforts to collect
and disburse restitution from those offenders on probation obtaining the victim
information when the crime is reported and communicating that information to the
appropriate collection and disbursing entities is lacking.
Response to Finding 7: The respondent disagrees partially with the finding. As
mentioned in the response to previous findings, the Probation Department is responsible
for determining victim losses if the offender is sentenced to formal probation. However, the
Probation Department is not responsible for determining victim losses if the offender is
sentenced to summary or informal probation.
8. Victims of misdemeanor crimes do not have their restitution orders actively collected
by the County.
Response to Finding 8: The respondent disagrees with the finding. If the restitution
order is for an undetermined amount, there is currently no further action because there is
nothing specific to collect. In misdemeanor cases with a specified restitution amount, the
Court actively pursues collection and also goes through the revenue recovery process for
collections. In misdemeanor cases resulting in formal probation, the Probation
Department collects restitution.
9. The restitution administration fee is currently being collected in an inefficient manner
and occasionally at a rate higher than authorized by State statute. The current practice
of the County is to collect the restitution administrative fee after the court-ordered
amount is satisfied. The Grand Jury is aware of the justification for this method;
however, research indicates the method of collecting administrative costs as payments
are received improves the Restitution Program’s ability to increase collections in future
years.
Response to Finding 9: The respondent disagrees with the finding. This finding is more
appropriately addressed by the Court because it is the Court (not the County) which
collects the restitution administration fee according to state Penal Code. The current
practice of collecting the restitution administrative fee after the court-ordered amount is
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satisfied is pursuant to state statute. The restitution administration fee is not collected at a
higher amount. The restitution administration fee is 10% of the restitution amount.
RECOMMENDATIONS
1. The District Attorney should convene a team of restitution activity experts to analyze
the feasibility and methodology that will best enhance restitution activities. The
Alameda County Restitution Program Managers, the Alameda County District
Attorney, the El Dorado County Superior Court, and the STAR volunteers are
supportive to formalizing and improving the County’s
Restitution program.
Response to Recommendation 1: The recommendation has been implemented. Within
existing resources, the Board of Supervisors will support the District Attorney’s approach
as outlined in his response to this report.
2. Increase victim services under the District’s Attorney’s Victim Witness Program,
utilizing the assistance of the STAR Program (volunteers). Increased services should
include:
 Early contact with all victims of crime to provide comprehensive county–
wide information on the restitution program
 Obtain and confirm current victim losses and addresses and a process for
victims to keep address information current and have that information
passed on to the State when appropriate.
Victim contact by the District Attorney’s Office will increase the success of identifying
victim losses and information needed to request a Court Order in an amount
commensurate with the loss, rather than an amount “to be determined.” Collection
cannot commence on orders to be determined where no dollar amount is stated.
Response to Recommendation 2: This recommendation does not appear to require a
response from the Board of Supervisors.
3. In conjunction with the entities involved in restitution process, the El Dorado County
District Attorney should adopt a more aggressive approach to the collection and
enforcement of restitution that includes actively collecting restitution resulting from
misdemeanor crimes. Delinquent accounts need to be identified and brought before the
Superior Court. Alameda County has received statewide recognition as a leader in
restitution enforcement with several counties in California successfully utilizing
Alameda County’s Restitution Enforcement Program as a model.
Response to Recommendation 3: The recommendation has been implemented. Within
existing resources, the Board of Supervisors will support the District Attorney’s approach
as outlined in his response to this report.
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Final Draft Response to the 2007-08 Grand Jury Final Report Part 3
4. To offset operational costs collect the administration fee, authorized by State statute, as
payments are received.
Response to Recommendation 4: The recommendation will not be implemented because
it is not reasonable. This recommendation appears to be directed at the Court however,
collecting the administration fee as payments are received violates Penal Code section
1203.1d
5. The Sheriff should analyze the feasibility of collecting restitution from offenders in the
County jails, prior to depositing cash received into the offender’s trust account. Hold
offenders accountable until final payment is made regardless if the offender is in jail,
on formal/informal probation, or work release programs.
Response to Recommendation 5: This recommendation does not appear to require a
response from the Board of Supervisors.
6. A team or restitution experts should develop a comprehensive restitution and
accounting system that tracks information from the date the crime is reported to the
release of the offender from County jurisdiction. Also the system should track accurate
records including the offender(s) name, case number, payment history, and link the
offender(s) to the appropriate victim(s). Lastly, the system should interface with State
systems.
Response to Recommendation 6: This recommendation will not be implemented because
it is not reasonable. Overall, this recommendation is cost-prohibitive. In addition, unless
the state took the initiative and funding responsibility, it is unlikely that a system could be
developed that interfaces with state systems. However the county is committed to analyzing
this problem from a multidisciplinary standpoint to create a more integrated approach to
victim restitution.
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